Subjective Exam and Comm Flashcards
What is the first part of the initial visit?
Establish if patient belongs in the clinic
What is step one of the subjective exam?
Review baseline/chart review
What is step two of the subjective exam?
establish rapport
What is step three of the subjective exam?
Gather general info
What is step four of the subjective exam?
analyze info/generate hypothesis
What is step five of the subjective exam?
Gather specific info (Date of onset, mode of onset, delayed or immediate symptoms, etc)
What is step six of the subjective exam?
Plan objective exam
What percentage of information needed to make a diagnosis is contained in the subjective exam?
80%
What are radicular symptoms?
direct stimulation of a nerve root
What type of pain results from radicular symptoms?
sharp, lancinating pain, well-localized to dermatomes
What is a visceral referral?
If the problem is organ based - kidney, pancreas, cardiac, etc
What type of pain can visceral pain mimic/masquerade as?
MSK
What type of referral is warranted when symptoms arise from MSK structure (i.e. facet joint)?
Somatic referral
What is a hypersensitive spot typically in skeletal muscle that can be associated with a taut band?
Trigger point
Behavior of symptoms is a part of what step of the exam review?
step 5
What are aggravating factors?
things that make it worse
What are easing factors?
things that make it better
What are red flags?
signs/symptoms that may warrant immediate communication with the referring provider or may warrant a referral to another provider
What are the categories of red flags?
- immediate attention
- require subjective questioning and precautionary exam and treatment procedure
- require further physical testing and differential analysis
What are yellow flags?
symptoms that warrant a referral/consult to a mental health practitioner
What are some examples of yellow flags?
psychosocial stress/fear avoidance, anxiety, depression, pain catastrophizing
What is SINSS?
Severity, Irritability, Nature, Stage, Stability
What are the levels of severity?
Minimal, moderate, high
How much does minimal severity affect activities?
do not limit
How much does moderate severity affect activities?
limit 40-70%
How much does high severity affect activities?
Severely reduces, inhibits activities
What are the levels of irritability?
low, moderate, high
What does irritability signify?
Time for symptoms to come and go
What irritability is someone who tolerates repetitive, sustained activity?
low
What irritability is someone who cannot tolerate the activity and pain takes more than 30 mins to subside?
high
What irritability is someone who tolerates brief activity and takes about 10 minutes to subside?
moderate
What are the options for nature?
MSK or nonMSK(Sinister)
What are the stages?
Acute, subacute, chronic
What is the time period for acute pain?
0-6 weeks
What is the time period for subacute pain?
6-12 weeks
What is the time period for chronic pain?
> 3 months
What does stability refer to?
whether the condition worsens, improves, or stays the same
What is the recognition of disease/disorder by a collection of signs and symptoms?
Diagnosis
What is the systematic method to identify cause (nature) of symptoms?
Differential Diagnosis
What is the predicted optimal level of improvement considering comorbidities, motivation, psychosocial factors, goals/expectation?
Prognosis
What are the general signs/symptoms present at time of visit?
constitutional signs
What are the questions during the subjective exam to gather information about the musculoskeletal system, cardiovascular system, integumentary system or other body systems?
Systems review
What is the ability for patients to come to PT on their own?
Direct access
What is Accessible healthcare by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients?
Primary care
What is Screening for malaise, fever, weight changes, nausea and vomiting?
General health screening
Which of the below is a scale used to quantify a patient’s pain rating that requires the patient to physically mark where their rating on a scale?
visual analog scale
What are the types of communication?
written, verbal, nonverbal
What type of communication includes skill in choosing the correct words and questions to ask as well as hearing and understanding the patient?
verbal
What type of communication is the nuances of behavior hat can be observed?
Nonverbal
What are some types of nonverbal communication?
Facial cues, tones, eye contact, body (language)
What are the sources of communication error?
Language, psychological, environmental, speech
What is language error?
Vocab understanding
What is psychological error for communication?
Is an emotion by the patient deflecting? i.e. stress, fear, sad
What is environmental error for communication?
what is the area like? is it noisy, temperature?, time of day? space?
What type of question is this?: What increases your pain?
open ended
What type of question is this?: Does moving this way increase pain?
Close ended
